health plan approaches to locating new medicare- medicaid ... · approximately 17,000 employees...
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www.chcs.org
January 13, 2015
Health Plan Approaches to Locating New Medicare-Medicaid Enrollees and Building Trusting Relationships
Promoting Integrated Care for Dual Eligibles (PRIDE) is supported by The Commonwealth Fund.
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About the Center for Health Care Strategies
A non-profit health
policy resource
center dedicated to
advancing access,
quality, and cost-
effectiveness in
publicly financed
health care
Introductions
Sarah Barth, JD Director of Integrated Health and Long-Term ServicesCenter for Health Care Strategies
Hany Abdelaal, DOPresident and CEOVisiting Nurse Service of New York (VNSNY) CHOICE (New York)
Anthony Evans, RN
Vice President for Integrated Health Services
CareSource (Ohio)
Maria Raven, MD, MPH, MSc
Assistant Professor of Emergency Medicine
University of California San Francisco
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I. Welcome and Introductions
II. Tips on Contacting Hard-to-Locate Medicare and Medicaid Members
III. Innovations at the Ground Level – Building Relationships with Health Plan Members
IV. Community Engagement Strategies and the Role of Navigators
V. Patient Engagement: Social Determinants of Health and the Role of Community Outreach
VI. Questions and Discussion
Agenda
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Questions?
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Your questions will be viewable only to panelists.
Answers to questions that cannot be addressed due to time constraints will be
shared after the webinar.
Promoting Integrated Care for Dual Eligibles (PRIDE)
• Supported by The Commonwealth Fund
• Brings together seven health care organizations to identify and test innovative strategies that enhance and integrate care for Medicare-Medicaid enrollees
• PRIDE participants:
- CareSource (OH) - Together4Health (IL)
- Commonwealth Care Alliance (MA) - UCare (MN)
- Health Plan of San Mateo (CA) - VNSNY CHOICE (NY)
- iCare (WI)
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Medicare-Medicaid Enrollees Face Challenges to Engagement
• 10 million Americans dually eligible for Medicare and Medicaid
• High need population:
► 20% have 3+ chronic conditions
► 30% have mental illness
► 44% receive long-term services and supports
• Many have unstable housing situations and supports
• Lower education and literacy levels
• Social determinants may affect ability to maintain health
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Tips for Contacting Hard-to-Locate Members
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1. Identify current providers from data
2. Maximize community partnerships
3. Send staff into the community
4. Use outreach staff
5. Target calls early in the month
6. Engage a broad group of partners
7. Establish electronic flag mechanisms
8. Assign specific staff
9. Knock on doorsSOURCE: S. Barth and B. Ensslin. Contacting Hard-to-Locate Medicare and Medicaid Members: Tips for Health Plans. Center for Health Care
Strategies, December 2014. Available at: http://www.chcs.org/media/PRIDE-Tips-for-Contacting-Hard-to-Locate-Members_121014_2.pdf.
Innovations at the Ground Level – Building
Relationships with Health Plan Members
Dr. Hany AbdelaalPresident, VNSNY CHOICE
Founded in 1893, VNSNY is the largest not-for-profit home and
community-based care organization in the United States
Provides a wide range of services across the continuum of care from
birth to end-of-life
VNSNY CHOICE (“CHOICE”) health plans serve over 40,000 members
Approximately 17,000 employees working in interprofessional teams
serve the most vulnerable and needy individuals
Serve over 65,000 patients per day
Co-developing population health initiatives with health systems, health
plans, and a national post-acute integrator through at-risk and bundled
payment contracts
VNSNY Snapshot
VNSNY has been at the forefront of innovative home and community-based models of
care for over 120 years
VNSNY Organization
Visiting Nurse Service of New YorkNot-For-Profit Parent Organization
Visiting Nurse
Service of New
York Home Care
Largest Certified Home
Health Agency in New York
metropolitan area
Partners in Care
Services
Licensed Home Care
Services Agency
VNSNY CHOICE
Health plans include two
MLTC plans1, four MA
plans, and a HIV-SNP plan
CHOICE VNSNY
VNSNY Hospice
and Palliative Care
Largest hospice program in
the New York metropolitan
area
Center for Home Care
Policy and Research
1 Includes CHOICE’s Managed Long-Term Care plan and VNSNY CHOICE Total, a Medicare HMO SNP and a Medicaid Advantage Plus FIDE-SNP plan, for dual eligibles
Plan Snapshot
CHOICE MLTC, MA, and HIV-SNP plans
CHOICE MLTC granted approval but currently no
membership
CHOICE MLTC and MA plans only
CHOICE MLTC plans only
Plan Overview
MLTC MA HIV-SNP
CHOICE currently serves members in 23 counties and
is licensed in an additional 10 counties
TOMPKINS
CHEMUNGTIOGA
CHENANGO
BROOME
CAYUGA
ONONDAGA
MADISON
LEWIS
JEFFERSON
ONEIDA
OSWEGO
ST LAWRENCE
SULLIVAN
ULSTER
ORANGE
DUTCHESS
PUTNAM
WESTCHESTER
ROCKLAND
DELAWARE
OTSEGO
CLINTON
ESSEX
FRANKLIN
HAMILTON
WARREN
FULTON
SCHOHARIE
MONTGOMERYSCHENECTADY
ALBANY
SARATOGA
GREENE
COLUMBIA
SUFFOLK
MONROE
ONTARIO
STEUBEN
YATES
WAYNE
CATTARAUGUS
ERIE
GENESEE
NIAGARA
ORLEANS
CHAUTAUQUA
WYOMING
ALLEGA
SCHUYLER
New York City
(Bronx, New York,
Queens, Kings,
Richmond)
Since its founding, CHOICE has become the MLTC market leader in New York State and expanded its plan offerings to include four MA plans and a Medicaid HIV-SNP plan
~17K Members ~19K Members~4.6K
Members
VNSNY CHOICE Care Management Philosophy
Health plans need to partner with community-based organizations rather than just contractwith them
VNSNY CHOICE uses both professional and non-professional staff to create a holistic care plan
- Care coordinators (RNs)
- Home health care workers (PCAs)
VNSNY CHOICE is committed to the health and wellness of the communities we serve
Take into account demographics and diversity of the population served
For cultural reasons some members may be unlikely to take advantage of community or health services
Tailoring Outreach to Specific Populations
The VNSNY Chinatown Community Center (since 1999) and Flushing Community Center (since 2012) are each open seven days a week
– Offer health screenings and educational workshops for over 2,000 CHOICE members
– Counsel on housing issues and mental health concerns
– Provide access to medical professionals and consultation with social workers
– Answer benefits questions and connect members to health plan staff, including care managers
– Offer a variety of classes and groups
– Host civic and social events
Reaching Out to Members via Community Centers
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
1 2 3 4 5
Home Care & You Home Care & You Health Screening Home Care & You Home Care & You
Consultation Consultation Cancelled Consultation Consultation
9:00am to 5:00pm 9:00am to 5:00pm 9:00am to 5:00pm 9:00am to 5:00pm
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Colon Cancer Home Care & You Free Flu Shots Health Care Proxy Glucose Screening*** Home Care & You VNSNY Choice
Screening Talk Consultation 10:00 am to 2:00 pm Consultation 10:00 am to 11:00 am Consultation Health Plans
By Li, Jian Jun MD 9:00am to 5:00pm NYPLMH 2:00pm to 4:00pm By Appointment 9:00am to 5:00pm 2014 Updates
11:00am to 1:00pm Health Talk By Appointment Workshops
CCBA 2nd Floor 10:00am to 4:00pm
1:00 pm to 2:00 pm
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VNSNY Choice VNSNY Choice Home Care & You Emergency Response Blood Pressure Screening*** Hepatitis B VNSNY Choice
Health Plans Health Plans Consultation By FDNY 10:00 am to 11:00 am Prevention Health Plans
2014 Updates 2014 Updates 9:00am to 5:00pm 1:00 pm to 3:00pm Manning Health Talk Health Talk 2014 Updates
Workshops Workshops By Appointment Confucius Plz Community Room By Jing, Wu Hua MD Workshops
10:00am to 12:00pm 10:00am to 12:00pm 3:30pm to 5:00pm 10:00am to 12:00pm 10:00am to 4:00pm
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VNSNY Choice Home Care & You Home Care & You SNAP Consultation Cholesterol Screening*** Home Care & You VNSNY Choice
Health Plans Consultation Consultation 10:00am to 12:00pm 10:00 am to 11:00 am Consultation Health Plans
2014 Updates 9:00am to 5:00pm 9:00am to 5:00pm Health Care Proxy Housing Consultaion 9:00am to 5:00pm 2014 Updates
Workshops Consultation By Appointment By CPC 2:30pm to 4:00pm Workshops
10:00am to 12:00pm 2:00pm to 4:00pm By Appointment Only 10:00am to 4:00pm
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VNSNY Choice Benefits Check Up Home Care & You Home Care & You Glucose Screening***
Health Plans By: CIDNY Consultation Consultation 10:00 am to 11:00 am
2014 Updates 2:00pm to 4:00pm 9:00am to 5:00pm 9:00am to 5:00pm By Appointment
Workshops By Appointment
10:00am to 12:00pm
Sample – Chinatown Community
Center’s Monthly Calendar
Open House
Health Workshop
Asian Health and Social Service Council Monthly Meeting
In 2015, the Retention Department will see an expansion as we will help retain our MLTC and FIDA members
With these new programs, we will accomplish the following:
– Disenrollment Surveys
– Home Visits
– Eligibility Verification
– Educational Events
– Medicaid assistance
– Member Search
– Member outreach
VNSNY CHOICE Outreach Strategy
Member Retention
Retention unit was created to reduce the VNSNY CHOICE Health Plans disenrollment rate, increase member satisfaction and impact the Stars scores
VNSNY Community Centers are open to the community at large – not just plan members
Community centers create partnerships with other community based organizations to assist with social and economic issues:
- Help pay bills
- Explain letters from CMS and other entities about eligibility and benefits
- Connect people with social service organizations (SNAP, energy and housing assistance)
Supporting the Larger Community
VNSNY CHOICE Retention Unit Structure
Title Number of Staff
Manager of Business Operations 1
Associate Program Manager 1
Supervisor of Medicaid Eligibility Coordinator
1
Program Assistant 7
Member Retention Representative 16
Member Retention Representative (Office Staff)
Member Retention Representative (Field Staff)
• Welcome Calls
• Orientation Calls
• Member Information Updates
• Medicare & Medicaid Eligibility
• Outbound Call Projects
• Disenrollment Surveys
• Transportation Assistance
• Community Centers
• Outreach Events
• Change-of-Options
• Member Home Visits
• Community Outreach Vehicles
• Medicaid, MSP, LIS, Community Services Assistance
• Surplus/ Income Pool Trust Assistance
Types of Services Retention Staff Provide
Community Engagement
Strategies and the Role of
Navigators
A n t h o n y E v a n s
V P I n t e g r a t e d H e a l t h
1 / 1 3 / 2 0 1 5
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CareSource
Non profit, mission-driven
Began Ohio’s first mandatory Medicaid MCP in 1989
One of the largest Medicaid HMOs in the US
Medicaid, Medicare, Exchange
Operations in Ohio, Kentucky, Indiana
• >1,000,000 Ohio Medicaid members
• >24,000 members in MyCare demonstration
28,000+ contracted providers
1,800+ employees
Headquarters based in Dayton, Ohio with regional offices in Cleveland, Columbus, Louisville and Indianapolis
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MyCare Ohio Regions
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Care Coordination
in Managed Care:
• Largely telephonic
• Low % of member participation
• High CM/member staffing ratios: 1:100s
• Minimal or no face to face interaction, limited environmental/social factor verification or assessment
• Medical and diagnosis/utilization driven care planning and interventions
• More focus needed on community based care, access, and transitions of care
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Emerging “High Touch” Models
• More members are actively care managed
• Intensive interdisciplinary team approach
focusing on in-person institutional and
community based interactions
• Full integration and coordination of physical,
behavioral, LTSS, social, and informal supports
• CM staffing ratios: 1:25 at highest acuities
• Targeted performance and quality measures
• Member engagement is a critical factor in
achieving outcomes- relationships matter
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Comprehensive Approach
• Strong community presence
• Well trained, visible and accessible staff
• Close collaboration with key stakeholders
• In person educational events and forums with:
– Members (institutional and in community)
– Community agencies, housing, and advocacy
groups
– Providers
• Cooperation with “safety net” organizations
• Deployment of community-based Navigators
Historical Perspectives
on Patient Navigation
Original concept
pioneered in 1990 by
Dr. Harold P. Freeman
Patient Navigator
Outreach and
Chronic Disease
Prevention Act of
2005
Oncology Nurse
Navigator movement
(National Coalition of
Oncology Nurse
Navigators)
Affordable Care Act
required “insurance
navigators” for
marketplace
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Navigation Defined
• “A strategy to improve outcomes in vulnerable
populations by eliminating barriers to timely diagnosis
and treatment of cancer and other chronic diseases”
• CareSource: The Navigator provides one-on-one
guidance, support, education, referral, coordination of
care, and other assistance to members as they move
through the healthcare continuum, as directed by the
CareSource Care Manager. As a member of the
CareSource Care Team, Navigators are accountable for
collaborating with other members of the team and
contributing to the implementation of the member’s care
plan.Freeman, H. P. and Rodriguez, R. L. (2011). History and principles of patient navigation. Cancer, 117: 3537–3540.
Accessed at http://onlinelibrary.wiley.com/doi/10.1002/cncr.26262/full
• Part of a member-centered care management model
• Scope of practice distinguishes the role and responsibility of the Navigator from other Care Team members.
• The primary function of the CareSource Navigator is to develop member relationships and assist the Care Team in identifying gaps in care
• Navigation is a cost-effective means to enhance the person-centered approach and maximize the impact and effectiveness of the Care Team
Freeman, H. P. and Rodriguez, R. L. (2011). History and principles of patient navigation. Cancer, 117: 3537–3540. Accessed at http://onlinelibrary.wiley.com/doi/10.1002/cncr.26262/full
Principles of Navigation
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Examples of
Navigator Activity• Accompany members to appointments and other
social service encounters when necessary
• Coordinate logistics for care plan adherence –reminders, transportation, and childcare arrangements
• Ensure that adherence issues/barriers are addressed by ongoing reporting of issues to Care Manager/Care Team
• Contribute to assessments by gathering information from the member, family, provider and other stakeholders
• Assist in education of member/caregivers regarding healthcare access and benefits
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Who Can Be A Patient
Navigator?
• Individuals at any level of education
may be employed as navigators.
• However, functions must be commensurate
with their level of education, experience,
and training
• Not a regulated profession
– No professional standards
– No national or state licensure
– No nationally recognized credential
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CareSource Navigator
QualificationsEducation:
High School Diploma or General Education Diploma (GED)
is required
Experience:
Two years of experience in either volunteer or paid
position working in community settings with at risk
populations providing coordination of services is preferred
Certification/Licensure/Background Check:
Harold P. Freeman Patient Navigation Institute Certificate, or
equivalent approved (internal) training program
Employment in this position is conditional pending successful
clearance of a driver’s license record check and criminal background
check.
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The Right Talent
• Recruiting appropriate skill sets at all levels is critical in
order to manage complex populations
Connect and communicate with diverse populations
(Cultural, literacy, social issues, language proficiency)
Understand community and local resources: live in the
neighborhoods in which they serve
Inquisitive, proactive, and self motivated
Look beyond the medical to identify psychosocial and
socioeconomic needs.
Problem solving
Caring, compassionate relationship builders
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Success Stories
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The Care Team
“No one can whistle a symphony.
It takes the whole orchestra to play it.”
~ H.E. Luccock
Patient Engagement: Social Determinants of Health and the Role of Community Outreach
Maria Raven, MD, MPH, MSc
Assistant Professor of Emergency Medicine
University of California, San Francisco
January 13, 2015
Outline
• Social determinants of health and the role of the health
care system
• Outreach strategies
• Engagement and trust-building tips
• Comprehensive assessment: what and how
• Maintaining connections
Social Determinants of Health
The Centers for Disease Control defines social
determinants of health as:
“Life enhancing resources such as food supply,
housing, economic and social relationships,
transportation, education and health care,
whose distribution across populations effectively
determines length and quality of life.”
Social Determinants of Health
• Implications:
• Patients (people) need access to care, insurance
coverage, food, income, housing, and transportation
• We’re getting better at access to care and insurance
coverage
• But how much does it matter if these other things are
missing?
Role of the Health Care System in
Addressing Social Determinants
• We are used to having relationships with patients in health
care settings
• Offices, ED, inpatient, etc.
• Or over the phone
• Many health plans and providers attempt telephonic outreach and
health care maintenance
• Operating within these realms leaves us unaware of key
aspects of people’s lives that are directly affecting their
health care
Role of the Health Care System in
Addressing Social Determinants
• Health plans and providers are not in patients’ homes and
communities
• Physical environment helps determine length and quality
of life: providers often unintentionally make assumptions
that can influence health outcomes
• Mold, domestic violence, access to safe outdoor space, danger of
eviction, homelessness, technology
• Increasingly, we’ll need to reach outside of our systems
(and comfort zones) to truly “reach” people
Health System-Community Partnerships
Key to Outreach, Engagement
• Health system is entry (and under-used intervention point) for homeless and other vulnerable populations–Despite repetitive use of health care system, little is
done to address underlying contributors to disease
• Partnerships improve communication, reduce care fragmentation
• Partnerships will often involve data sharing agreements• Don’t let this scare you
• Health plans may have advantages
Outreach Strategies
• Often, individuals who could most benefit from improved
connections to health care services can be the most
challenging to find
• Individuals may be unaware of:
• Auto-enrollment into health plans or other networks of care
• Eligibility for coverage and other benefits
• Individuals may have had poor experiences with the
health care system in past and be hesitant to respond to
outreach attempts
Outreach Strategies
• In person outreach
• “Vet” individuals using multiple databases if accessible
• SFHP as example
• Consider appointments or providers as potential points of
contact
• Technologic innovations
• Cell phones, patient alert system, unified EMRs
• Outreach to and data sharing with community organizations
• MOUs likely needed
Once Contact Is Made: Engagement
• Simple way to engage and build trust
• Understand health and community services networks
where eligible patients can receive needed services
right off the bat
• If in person, offer a cup of coffee
• Hire and train the right staff
• Take the needed time
• Often, more than one visit will be needed
Comprehensive Assessment: If You Don’t
Ask, You’ll Never Know
• Multiple examples exist of validated question sets and
surveys that cover multiple domains relevant to social
determinants of health
• Social Support
• Legal Issues
• Housing history and living environment
• Substance use
• Mental Health
• Transportation access
• Technology access
Social Support Question Examples
I would like to learn a little bit more about your relationships
with friends and family over the course of your life.
• In your life now, do you have a close friend or family
member in whom you can confide or talk to about yourself
and your problems?
• How many close friends or relatives do you have?
• Is there someone who will lend or give you money if you
need it?
• Do you have someone who will take you in if you need a
place to stay?
Housing Question ExamplesThe next few questions are about where you have stayed in the last 6 months, and about the last time you had a stable place to live.
• On the streets, a park, a vehicle, an abandoned building, a bus/train/BART station/airport, or anywhere outside or inside not meant for human habitation
• In a garage, backyard, porch, shed or driveway
• In a homeless shelter for single adults or families
• In transitional housing for homeless adults or families (where you pay rent and can live up to two years and receive services)
• In permanent housing for formerly homeless people (such as Shelter plus Care, the Harrison Hotel, or UA Homes)
• In a hotel or motel or campground paid for by an agency, church or other service provider for a short stay of one week or less
• In a hotel or motel arranged for and paid for by you or a family member where you stayed for less than 30 days in a row or the hotel asked you to move out after 28 days
• In a hotel or motel room arranged for and paid for by you or a family member where you had stayed for more than 30 days in a row
• In a room you rent in a house or apartment
• In an apartment or house you rent
• In an apartment, condo or house that you own•
Comprehensive Assessment and
Implications of Asking• If you ask, then you need to be prepared to:
• Listen
• Intervene
• Multiple techniques exist for approaching patients in ways that can allow for trust to be built• Time is important: the 15 minute office visit is probably not the right
setting
• Motivational interviewing
• Trauma informed care
• Intervening can mean a lot of different things
• Asking about housing does not imply you need to provide housing if someone is homeless
• It may mean you should determine housing eligibility or refer to someone who can
Maintaining Connections: Phones or In-
person?• Telephonic management alone does not work,
especially for homeless and other vulnerable
populations
• Difficult to find, keep in contact with
• Studies show mobile phones more common than
landlines
• Mobile phone possession and service can be
intermittent
• That said, consider connecting eligible individuals
to free low-income phone services
Mobile Phone Project
Maintaining Connections: Staff Matters
• Consider that non-licensed staff may be more willing and
more effective in some situations
• Experience counts
• Interview candidates carefully
• Train staff appropriately
• Local resources
• Housing question set
• Motivational interviewing
• Trauma informed care
• Assure non-licensed staff have adequate supervisory
support
Maintaining Connections: Assessment
and Community Connections
• Comprehensive assessment is a living document
• Updates, changes, indications of goal completion or new
goal/intervention input should be expected
• Consider interval reassessments to evaluate progress
• Establishing connections with individuals’ other providers
(e.g. housing, PCP, case manager) is key
• Continue to be aware of changing community resources
Questions?
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To submit a question please click the question mark
icon located in the toolbar at the top of your screen.
Your questions will be viewable only to panelists.
Answers to questions that cannot be addressed due to time constraints will be
shared after the webinar.
Contact Information
• Sarah Barth [email protected]
• Hany Abdelaal [email protected]
• Anthony Evans [email protected]
• Maria Raven [email protected]
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